Family Involvement In Relapse Prevention

Since 1980 there has be compelling evidence in the scientific literature that when families are appropriately involved with their addicted family members in treatment, the long-term recovery rate goes up, the relapse rate goes mown, and the general health and well being of family members improves significant.

This blog contains a more detailed exploration of Family involvement In Relapse Prevention. The scope of family involvement may surprise you

In many cases the addict is the first family member to seek treatment. Other family members become involved in order to help the alcoholic get sober. Many family members refuse to consider the fact that they also have a problem that requires specialized treatment. These family members tend to deny their role in their addicted family and scapegoat personal and family problems upon the addicted person. They develop unrealistic expectations of how family life will improve with their loved one getting abstinent. When these expectations are not met, they blame the addict for the failure, even though he or she may be successfully following a recovery program. Their attitudes and behaviors can become such complicating factors in the addict’s recovery that they can contribute to the process of relapse and even “set-up” the addict’s next “episode of use.”

On the other hand family members can be powerful allies in helping the addict prevent fully engaging the relapse process. Relapse Prevention Planning utilizes the family’s motivation to get the addict sober. As family members become involved in relapse prevention planning, a strong focus is placed upon co-addiction and its role in the family relapse process. Family members are helped to recognize their own co-addiction and become actively involved in their own treatment. Addiction is a family disease that affects all family members, requiring everyone to get involved in treatment. The addict needs treatment for addiction. Other family members need treatment for co-addiction.

The term “co-addiction” is sometimes used to refer only to the spouse of an addict and other terms are used to refer to other family members. We are using the term “co-addict” to refer to ANYONE WHOSE LIFE HAS BECOME UNMANAGEABLE AS A RESULT OF LIVING IN A COMMITTED RELATIONSHIP WITH AN ADDICTED PERSON.

Co-addiction is a definable syndrome that is chronic and follows a predictable progression. When persons in a committed relationship with an addicted person attempt to control drinking, drug use, or addictive behavior (over which they are powerless), they lose control over their own behavior (over which they can have power) and their lives become unmanageable.

When you try to controlWhat you are powerless overYou lose controlOver what you can manage.

The person suffering from co-addiction develops physical, psychological, and social symptoms as a result of attempting to adapt to and compensate for the debilitating effects of the stress of living with someone who is addicted. As the co-addiction progresses, the stress-related symptoms become habitual. The symptoms also become self-reinforcing; that is, the presence of one symptom of co-addiction will automatically trigger other co-addiction symptoms. The co-addiction eventually becomes independent of the addiction that originally caused it. The symptoms of co-addiction will continue even if the addicted person in the family becomes sober or joins AA/NA, or the co-addict ends the relationship.

The condition of co-addiction manifests itself in three stages of progression.

Early Stage: Normal Problem Solving and Attempts to Adjust

The normal reaction within any family to pain, to crisis, and to the dysfunction of one member of the family is to do what they can to reduce the pain, ease the crisis, and to assist the dysfunctional member however possible in order to protect the family. These responses do not make things better when the problem is addiction, because these measures deprive the addicted person of the painful learning experiences that bring an awareness that his/her addiction is creating problems. At this stage, co-addiction is simply a reaction to the symptoms of addictive disease. It is a normal response to an abnormal situation.

Middle Stage: Habitual Self-Defeating Responses

When the culturally prescribed responses to stress and crisis do no bring relief from the pain created by the addiction in the family, the family members TRY HARDER. They do the same things, only more often, more intensely, mores desperately. They try to be more supportive, more helpful, more protective. They take on the responsibilities of the addicted person, not realizing that this causes the addict to become more irresponsible.

Things get worse instead of better and the sense of failure intensifies the response. Family members experience frustration, anxiety, and guilt. There is growing self-blame, lowering of self-concept, and self-defeating behaviors. They become isolated. They focus on the addict’s addictive behavior and their attempt to control it. They have little time to focus on anything else. As a result they often lose touch with the normal world outside of their family.

Chronic Stage: Family Collapse and Stress Degeneration

The continued habitual response to addiction in the family results in specific repetitive, circular patterns of self-defeating behavior. These behavior patterns are independent and self-reinforcing and will persist even in the absence of the symptoms of addictive disease.

The things the family members have done in a sincere effort to help have failed. The resulting despair and guilt bring about confusion and chaos and the inability to interrupt dysfunctional behavior even when they are aware that what they are doing is not helping. The thinking and behavior of the co-addict is OUT OF CONTROL, and these thinking and behavior patterns will continue independent of the addiction.

Co-addict degeneration is bio-psycho-social. The ineffective attempts to control drinking and drugging behavior elevate chronic stress to the point of producing stress-related physical illnesses such as migraine headaches, ulcers, and hypertension. This chronic stress may also result in a nervous breakdown or other emotional illnesses. Out-of-control behavior itself is an addiction-centered lifestyle that pervades all life activity, even that which seems unrelated to the addiction. Social degeneration occurs as the addiction focus interferes with relationships and social activity. Spiritual degeneration results, as the focus on the problem becomes so pervasive that there is no interest in anything beyond it, particularly concerns and need related to a higher meaning of life.

Recovery from co-addiction means learning to accept and detach from the symptoms of addiction. It means learning to manage and control the symptoms of co-addiction. It means learning to focus on personal needs and personal growth, learning to respect and like oneself. It means learning to choose appropriate behavior. It means learning to be in control of one’s own life.

Because it is a chronic condition, co-addiction, like addiction, is subject to relapse. But a condition of co-addict relapse may be more difficult to identify. Without an ongoing recovery program and proper care of oneself, old feelings and behaviors thought to be under control may surface and become out of control. Life again becomes unmanageable; the co-addict is in relapse mode.

RELAPSE WARNING SIGNS FOR CODEPENDENCY

From the observation of counselors who have worked with recovering family members, relapse warning signs for the co-addicted significant other have emerged. The following list has been compiled from these observations.

1. Situational Loss of Daily Structure. The family member’s daily routine is interrupted by a temporary situation such as illness, the children’s schedule, the holidays, vacation, etc. After the event or illness, the significant other does not return to all of the activities of his or her recovery program.

2. Lack of Personal Care. The significant other becomes careless about personal appearance and may stop doing and enjoying small things that are “just for own personal enjoyment.” The person returns to taking care of others first and self second or third.

3. Inability to Effectively Set and Maintain Limits. The significant other begins to experience behavioral problems with the children or roommates. Limits that are being set tend to be too lenient or too rigid and result in more discipline problems.

4. Loss of Constructive Planning. The significant other begins to feel confused and overwhelmed by personal responsibilities. Instead of deciding what is most important and doing that, he or she begins to react by doing the first thing that presents itself, while more important jobs go undone.

5.Indecision. The significant other becomes more and more unable to make decisions related to daily life.

6. Compulsive Behavior. The significant other experiences episodes during which he or she feels driven to do more. Whatever has already been done does not seem to be enough.

7.Fatigue or Lack of Rest. He or she becomes unable to sleep the number of hours necessary to feel rested. When sleep does occur, it is fitful.

8. Return of Unreasonable Resentments. The significant other finds himself or herself mentally reviewing persons or events that have hurt, angered, or been generally upsetting. As these are reviewed, the significant other relives the old emotions and feels resentments about them.

9. Return of the Tendency to Control People, Situations, and Things. As the co-addicted significant other feels less control over life, he or she begins openly to try to control and manipulate other people or situations. The addicted person may be the prime target, but does not necessarily have to be.

10.Defensiveness. The co-addicted person may not totally approve of some of his or her own actions, but when challenged about them will openly justify the actions in a sharp or angry way.

11. Self-Pity. The co-addict begins to dwell on problems from the present or the past and in turn begins to magnify them. The significant other person may ask, “Why does everything always happen to me?”

12.Overspending/Worrying about Money. The significant other may be very concerned about the family finances, yet impulsively spends money in order to “feel better.” He or she becomes convinced that what was purchased was deserved, but ends up feeling guilty and even more trapped.

13. Eating Disorder. The significant other “loses” his or her appetite to the point that even favorite foods are not appealing. Or the significant other may begin to overeat, regardless of appetite, in order to feel better. The overeating satisfies for only a very short time, or not at all.

14.Scapegoating. There is an increasing tendency to place the blame on other people, places, and things. The co-addict looks outside of self for the reasons why he or she is feeling bad.

15.Return of Fear and General Anxiety. The significant other begins to experience periods of time when he or she is nervous. Situations that previously did not cause fear or anxiety are now causing those emotions. The significant other may not even know the source of the nervousness.

16. Loss of Belief in a Higher Power. The significant other begins to lose belief in a higher power, whatever it may be. There is a tendency to rely more on self-alone, or to turn to the addict for strength and the solutions.

17.Attendance at Al-Anon Becomes Sporadic. The significant other changes the pattern of Al-Anon meeting attendance. He or she may go to fewer meetings, thinking there isn’t time, the meetings aren’t helping, or are not needed.

18. Mind Racing. The significant other feels as though he or she is on a treadmill that is going too fast. In spite of attempts to slow down, the mind continues to race with the many things that are undone or the problems that are unsolved.

19.Inability to Construct a Logical Chain of Thought. The significant other tries to solve problems and gets stuck on something that would normally be simple. It seems that his or her mind does not work anymore, that it is impossible to figure out the world. As a result, he or she feels powerless and frustrated with life.

20.Confusion. The significant other knows they are feeling out-of-sorts, but don’t know what is actually wrong.

21.Sleep Disturbance. Sleeplessness or fitful nights become more regular. The more the person tries to sleep, the less he or she is able to. Sleep may come, but it is not restful. The significant other looks tired in the morning instead of rested.

22.Artificial Emotion. The co-addict significant other begins to exhibit feelings without a conscious knowledge of why. He or she may become emotional for no reason at all.

23.Behavioral Loss of Control. The co-addict begins to lose control of his or her temper especially around the addict and/or the children or roommates. Loss of behavioral control is exhibited in such ways as over-punishing the children, hitting and yelling at the addict, or throwing things and tantrums.

24.Uncontrollable Mood Swings. Changes in the co-addict’s moods happen without any warning. The shifts are dramatic. He or she no longer feels somewhat down or somewhat happy, but instead goes from feeling extremely happy to extremely low.

25.Failure to Maintain Interpersonal (Informal) Support Systems. The co-addict stops reaching out to friends and family. This may happen very gradually. He or she turns down invitations for coffee, misses’ family gatherings, and no longer makes or returns phone calls.

26.Feelings of Loneliness and Isolation. The co-addict begins to spend more time alone. He or she usually rationalizes this behavior – too busy, the children, school, job, etc. Instead of dealing with the loneliness, the co-addict becomes more compulsive and impulsive. The isolation may be justified by convincing him or herself that no one understands or really cares.

27.Tunnel Vision. No matter what the issue or situation might be, the co-addict focuses in on his or her opinion or decision and is unable to see other points of view. He or she may become close-minded.

28.Return of Periods of Free Floating Anxiety and/or Panic Attacks. The co-addict may begin to re-experience, or experience for the first time, waves of anxiety that seem to occur for no specific reason. He or she may feel afraid and not know why. These uncontrollable feelings may snowball to the point that he or she is living in fear of fear.

30.Use of Medication or Alcohol as a Means to Cope.Desperate to gain some kind of relief from the physical and/or emotional pain, the co-addict may begin to drink, use drugs, or take prescription medications. The alcohol or drug use provides temporary relief from the growing problems.

31.Total Abandonment of Support Meetings and Therapy Sessions. Due to a variety of reasons (belief that he or she no longer needs the meetings, immobilizing fear, resentment, etc.), the co-addict completely stops going to support meetings or to therapy or both.

32.Inability to change self-defeating behaviors. While there is recognition by the co-addict that what is being done is not good for himself or herself, there is still the compulsion to continue the behavior in spite of that knowledge.

33.Development of an “I Don’t Care” Attitude. It is easier to believe that “I don’t care” than it is to believe that “I am out of control.” In order to defend self-esteem, the co-addict rationalizes, “I don’t care.” As a result, a shift in value system occurs. Things that were once important now seem to be ignored.

34.Complete Loss of Daily Structure. The co-addict loses the belief that an orderly life is possible. He or she begins missing (forgetting) appointments or meetings, is unable to have scheduled meals, to go to bed or get up on time. The co-addict is unable to perform simple acts of daily function.

35.Despair and Suicidal Ideation. The co-addict begins to believe that the situation is hopeless. He or she feels that options are reduced to two or three choices: going insane, committing suicide, or numbing out with medication, and/or alcohol, drugs or maladaptive, perhaps compulsive behavior.

36.Major Physical Collapse. The physical symptoms become so severe that medical attention is required. These can be any of a number of symptoms that become so severe that they render the co-addict dysfunctional (e.g., an ulcer, migraines, heart pains, or heart palpitations).

37.Major Emotional Collapse. Having seemingly tried everything to cope, the co-addict can conceive no way to deal with his or her unmanageable life. At this point the co-addict may be so depressed, hostile, or anxious that he or she is completely out of control.

RELAPSE PREVENTION FOR THE FAMILY

While each family member is responsible for his or her own recovery and no one can recover for another, the symptoms of addiction and co-addiction each impact upon the relapse potential of the other. Even if the alcoholic/addict is no longer drinking or using and no longer experiencing the alcohol/drug-related symptoms of the disease, the post acute withdrawal symptoms affect and are affected by co-addiction. Both the symptoms of post acute withdrawal and the symptoms of co-addiction are stress sensitive. Stress intensifies the symptoms and the symptoms intensify stress. As a result, the recovering addict and the co-addict can become a stress-generating team that unknowingly and unconsciously complicates each other’s recovery and create a high risk of relapse.

What can family members do to reduce the risk of their own relapse and the risk of relapse in the recovering addict? They can become informed about the addictive disease, recovery, and the symptoms that accompany recovery. They must recognize that the symptoms of post acute withdrawal are sobriety-based symptoms of addiction rather than character defects, emotional disturbances, or mental illness. At the same time they must accept and recognize the symptoms of co-addiction and become involved in Al-Anon and/or personal therapy as they develop plans for their own recovery.

Clinical experience with relapse prevention planning in a variety of treatment programs has indicated that the family can be a powerful ally in preventing relapse in the addict. In 1980, relapse prevention planning was modified to include the involvement of significant others including family members. This significantly increased effectiveness. With further clinical experience, however, other problems became apparent. Many family members refused to participate in relapse prevention planning. Other family members participated in a manner that was counterproductive.

In 1983 relapse prevention planning was expanded to include relapse prevention in both the addicted person and the co-addict. The newly designed relapse prevention planning protocol utilizes the family’s motivation to get the addict sober. As family members become involved in relapse prevention planning, a strong focus is placed upon co-addiction and its role in family relapse. Family members are helped to recognize their own co-addiction and become actively involved in their own treatment. Addiction is presented as a family disease that affects all family members requiring them to get treatment.

All members of an addicted family are prone to return to self-defeating behaviors that can cause them to become out of control. An acute relapse episode can occur with an addict or a co-addict family member. Like addicts who develop serious problems even though they never use alcohol or drugs, the co-addict often becomes dysfunctional even though the addict is sober and working an active recovery program.

It is important to protect the family from the stress that may be generated by the symptoms of post acute withdrawal experiences by the recovering person and to cooperate in plans to protect the recovering person from stress created by symptoms of co-addiction. Remember that none of you became ill overnight. Recovery will, likewise, take place over a long period of time. Develop a plan to prevent personal relapse and support relapse prevention plans for the recovering addict.

Family Relapse Prevention Planning is intended to help prevent acute relapse episodes in the recovering addict, to prevent crisis in the co-addict, to develop a relapse prevention plan for both the addict and co-addict and to develop an early intervention plan to interrupt acute relapse episodes in both the recovering addict and the co-addict. For the addict this involves interrupting problems that are caused both by Post Acute Withdrawal (PAW) Syndrome in the sober addict and by alcohol or drug use in the addict who has returned to drinking or using. For the co-addict this involves interrupting the co-addiction crisis. The family needs to work with a counselor to establish a formal relapse prevention plan that will allow them to support each other’s recovery and to help intervene if the relapse warning symptoms get out of control.

The family relapse prevention planning protocol consists of twelve basic procedures. These are:

1. Stabilization: The first step in relapse prevention planning is to stabilize both the addict and the co-addict. The addict is stabilized through the process of detoxification or treatment of post-acute withdrawal symptoms. The spouse is stabilized by treating the co-addict crisis, through detachment from the addicts crisis, by regaining a reality-based perspective, and the development of some basic personal strengths. This often requires attendance at Al-Anon and professional counseling.

2. Assessment: Prior to developing a relapse prevention plan it is necessary to evaluate the addict, the co-addicts, and the family system.The evaluation should assess the current problems of each family member, their willingness and ability to initiate a personal recovery program, and their willingness to become involved in a program of family recovery.

3. Education about Alcoholism, Co-addiction, and Relapse:Accurate information is the most powerful of all recovery tools. The addict and the family must learn about the disease of addiction, the condition of co-addiction, treatment, and relapse prevention planning. This education is best provided to the family as a unit in multiple family classes. It is helpful if separate group therapy programs accompany the education for each family member. The addict should enter an addict group, the adult co-addict should enter a spouse’s group, and the co-addict children should enter a children’s group. It is in these group treatment sessions that individual recovery of all family members is initiated.

4. Warning Sign Identification: Both the addict and the co-addict need to identify the personal warning signs that indicate that they are becoming dysfunctional. Again, this is best done in a group setting. The addict is better able to identify relapse-warning signs when working with other addicts. Co-addicts are best able to initially identify relapse-warning signs when working with other co-addicts. Relapse warning sign lists for addiction and co-addiction are useful guides for personal warning sign identification.

5. Family Validation of Warning Signs: After each family member has developed a personal list of warning signs and reviewed these in his or her group, a series of family sessions is scheduled. During these sessions all family members present their personal lists of warning signs and ask for feedback. Other family members discuss the warning signs, help assess fi they are specific and observable. New warning signs may be added to the list based upon the feedback of others. Since each family member has a list of warning signs that precede acute relapse episodes there is no identified patient. All participate from a position of equality. They essentially say to each other, “We have all been equally affected, in various ways, by addictive disease.”

6. The Family Relapse Prevention Plan: Family members discuss each of their warning signs, how the family has dealt with those warning signs in the past, and what strategies could be effectively used in the future. Future situations in which the warning signs are likely to be encountered are identified. Strategies for more effective management of the warning signs for each family member are discussed. During this process a great deal of role playing and problem solving occurs. Problems are often identified that are taken back to the separate therapy groups for further work.

7. Inventory Training: All member of the family receive training in how to complete a morning planning inventory and an evening review inventory. These focus heavily upon time structuring, realistic goal setting, and problem solving.

8. Communication Training: The family members must learn to communicate effectively in order for a Relapse Prevention Plan to work. The family is trained in the process of giving and receiving feedback in a constructive and caring manner.

9. Review of the Recovery Program: All family members will report to the family the recovery program that they have established for themselves. This focus here is, “How will you and I know that I am doing well in my recovery?” All are invited to express their recovery needs and point out their progress in treatment.

10. Denial Interruption Plan: Both addiction and co-addiction are diseases of denial. Most of the denial is unconscious. Neither the addict nor the co-addict realizes that they are in denial when it is happening. It is important to take the reality of denial into account early. Each family member should be asked the question, “What are other people in your family supposed to do if they give you feedback about concrete warning signs and you deny it, ignore the feedback, or become angry and upset?” Each family member should recommend specific plans for dealing with their own denial. This open discussion sets the stage for intervention should denial become a problem in the future.

11. The Relapse Early Intervention Plan: Addiction and co-addiction are prone to relapse. Relapse means becoming dysfunctional in recovery. For the recovering addict relapse may ultimately lead to alcohol and drug use, or it may simply mean that the person becomes so depressed, anxious, angry, or upset that he is dysfunctional in sobriety. For the co-addict relapse means the return to a state of co-addict crisis that interferes with normal functioning. Once family members enter an acute relapse episode they are out of control of their thoughts, emotions, judgements, and behavior. They often need the direct help of other family members to interrupt the crisis. Many times they resist this help. They act as if they do not want help even though they desperately need it. The family is instructed in the process of intervention. Intervention is a method of helping people who refuse to be helped. This intervention training has resulted in a radical decrease in the duration and severity of relapse episodes in family members.

12. Follow–up and Reinforcement: Addiction and co-addiction are life-long conditions. The symptoms can go into remission but they never totally disappear. They rest quietly, waiting for a lapse in the recovery program to become active again. It is important that the family maintain an ongoing recovery program including AA/NA, Al-Anon, and periodic relapse prevention checkups with a professional addiction counselor.